Patient Acknowledgements and Authorizations

Welcome! At Temple City Dental Care, we are committed to providing you with the best possible dental care and helping you achieve your optimum oral health. We feel that you deserve nothing less when it comes to your health. We use the best materials and techniques available to provide you quality dental care.

We believe that our relationship with you, as with all relationships, needs open and clear communication. We will try to communicate all your dental needs and estimate your financial information as soon as it becomes evident. We want you to be as informed as possible to help you in your decisions concerning your dental health.

We understand how valuable your time is, so we make every effort to remain on time. We do not double book our appointments. We feel that you deserve our complete and focused attention so that we may provide the best care possible. Your reserved time is exclusively yours.

Towards these goals, we would like to explain your financial and scheduling responsibilities with our practice.

Your Commitment (Patient Responsibilities)

We want you to be comfortable with our team. If you ever have any questions about your dental treatment, financial or insurance-related questions, or any concerns at all, we ask that you notify us as soon as possible. We will be glad to clarify any uncertainties that may arise.

Payment: Payment is due at the time services are rendered. Financial arrangements are discussed during the initial visit and a financial agreement is completed in advance of performing any treatment with our practice. We accept the following forms of payment: Cash, Check, and the following credit cards – American Express, Master Card, Discover, and Visa. We also offer third-party financing, which includes both interest-free programs and extended financing. Note: If you elect to apply for third-party financing, administered through our practice, we are required by law to provide you with a Credit for Dental Services Notice.

Dental Benefit Plans: Your dental benefit is a contract between you or your employer and the dental benefit plan. Benefits and payments received are based on the terms of the contract negotiated between you and your employer and the plan. We are happy to help our patients with dental benefit plans to understand and maximize their coverage.

We kindly ask that you realize we do NOT work for an insurance company. Rather, we work 100% for our patients. We feel that insurance can be a great benefit for many patients and want you to know we will do everything in our power to ensure you get every benefit allotted in your insurance contract. However, the treatment we recommend and the fees we charge WILL ALWAYS BE BASED ON YOUR INDIVIDUAL NEEDS, NOT YOUR INSURANCE COVERAGE.

If we are a contracted provider with your plan, you are responsible only for your portion of the approved fee as determined by your plan. We are required to collect the patient’s portion (deductible, co-insurance, co-pay, or any amount not covered by the dental benefit plan) in full at time of service. If our estimate of your portion is less than the amount determined by your plan, the amount billed to you will be adjusted to reflect this.

If we are not a contracted provider with your dental benefit plan, it is the patient’s responsibility to verify with the plan whether the plan allows patients to receive reimbursement for services from out-of-network providers. If your plan allows reimbursement for services from out-of-network providers, our practice can file the claim with your plan and receive reimbursement directly from the plan if you “assign benefits” to us. In this circumstance, you are responsible and will be billed for any unpaid balance for services rendered upon receipt of payment from the plan to our practice, even if that amount is different than our estimated patient portion of the bill. If you choose to not “assign benefits” to our practice, you are responsible for filing claims and obtaining reimbursement directly from your dental benefit plan and will be responsible for payment to our practice before or at the time of service.

Scheduling of Appointments: We reserve the doctor and the hygienist’s time on the schedule exclusively for each patient procedure and are diligent about being on time. Because of this courtesy, when a patient cancels an appointment, it affects the overall quality of service we are able to provide. We understand that circumstances may arise that require an appointment to be rescheduled; however, to maintain the utmost service and care, we do require a 48-hour notice to reschedule an appointment. With less than a 48-hour notice, a fee of $50.00, or deposit to reserve the appointment time again, may be required. To serve all our patients in a timely manner, we may need to reschedule an appointment if a patient is 15 minutes late or more arriving to our practice. To reschedule an appointment due to late arrival, a fee of $50 or deposit to reserve the next appointment, may be required.

Your scheduled appointment is reserved exclusively for you. We have a 48 hour cancellation policy in order to provide you with the personalized attention. We understand that circumstances may arise that require an appointment to be rescheduled. We are happy to change your reservation time if a 48 hour notice is given. If sufficient notice is not given, your account will be charged a $50 broken/missed appointment fee. We ask that you make every effort to keep your reserved time.

Patient Authorization

I understand that the information I have given today is correct to the best of my knowledge. I authorize the dental team to perform any necessary dental services that I may need and have consented to during diagnosis and treatment.

I have read the above and agree to the financial and scheduling terms.

I authorize the release of information necessary to process my dental benefit claims.
I hereby authorize payment directly to this doctor otherwise payable to me.

Yes

No

Patient Communications

Messages: I understand brief messages from the dental practice may be left on my home answering machine or with anyone who answers the telephone at my home unless I have provided the practice with alternate instructions for communication.

Email: Except for appointment reminders, we use secure methods to electronically communicate with our patients. Unencrypted email is not a secure form of communication. There is some risk that any individually identifiable health information and other sensitive or confidential information that may be contained in such email may be misdirected, disclosed to or intercepted by unauthorized third parties. However, you may consent to receive unsecured email from us regarding your treatment. We will use the minimum amount of protected health information in any communication.

Please select one of the following three (3) options, initial, and provide your email address.

I do consent and accept the risk of receiving information via unsecured email. I understand I can withdraw my consent at any time.

I do consent to receive ONLY appointment reminders via unsecured email. I understand I can request an alternate method of appointment reminders at any time.

Email address:

I do not consent to receiving any information via email. I understand that I can change my mind and provide consent later.

Mobile Phone

I do consent to the dental practice using my mobile phone number regarding appointments and to call regarding treatment, insurance, and my account. I understand that I can withdraw my consent at any time.

Please select one or both.

Call

Text

I do not consent to the dental practice using my mobile phone number to either call or text. I understand that I can change my mind and provide consent later.

Patient Acknowledgements

I hereby acknowledge that a copy of this practice’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

I understand that as part of my health care, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I hereby acknowledge that I have been provided with and understand that this facility’s Notice of Privacy Practices provides a complete description of the uses and disclosures of my health information. I understand that:

I have the right to review the facility’s Notice of Privacy Practices prior to signing this acknowledgement.

This facility reserves the right to change their Notice of Privacy Practices and prior to implementation of this will mail a copy of any revised notice to the address I have provided if requested.

Patient's or Personal Representative's Name

Relationship (if not patient)

Reset Signature

Date:

Patient Information

Please allow 5 - 10 minutes to complete the form.

* = required

First Name*

Middle Name or Initial

Last Name*

I preferred to be called

Gender*

Male Female

Date of Birth*

Age*

Social Security number

Marital Status

Single

Married

Divorced

Separated

Widowed

Best time to reach you?

How did you hear about us?

Driver's License/ID#

Person to contact in case of emergency

Their phone #

Home Address

Address*

City*

State*

Zip*

Contact Information

Home Phone*

Mobile Phone

Work Phone

Email*

Employer

Occupation

Business Address

Spouse Information

Date of Birth

Social Security number

Employer Info

Employer Phone #

Occupation

Business Address

Referring Doctor or Dentist

Emergency Contact

(Name of Relative of Friend, not living with you)

Emergency contact name*

Emergency contact phone*

Emergency contact relationship*

Emergency contact address*

Insurance Information

Dental coverage?

Yes No

Orthodontic coverage?

Yes No

Medical coverage?

Yes No

Dental Insurance Company

Dental Insurance Company Phone

Group number

Member number

Dental Insurance Company Address

Insured's Employer

Insured's Employer Address

Insured's Employer Phone

Insured's Name

Relationship to patient

Insured's SSN

Insured's DOB

Do you have secondary Dental insurance?

Yes No

Secondary Insurance

Dental coverage?

Yes No

Orthodontic coverage?

Yes No

Medical coverage?

Yes No

Dental Insurance Company

Dental Insurance Company Phone

Group number

Member number

Dental Insurance Company Address

Insured's Employer

Insured's Employer Address

Insured's Employer Phone

Insured's Name

Relationship to patient

Insured's SSN

Insured's DOB

Assignment of Insurance Benefits

I hereby authorize Temple City Dental Care to furnish information to insurance carriers concerning treatment and hereby assign to the doctors all payments for dental services rendered. This assignment will remain in effect until revoked by me in writing; a photocopy of this assignment is as valid as an original.
I understand that I am financially responsible for all charges whether or not paid by said Insurance/Dental Plan. I hereby authorize said assignee to release all information necessary to secure payment.
I authorize Jack Von Bulow, DDS, or the attending dentist to examine and provide medical/dental treatment. I assume full responsibility for any balance due. I authorize my insurance company to pay by check made out directly to Jack Von Bulow, DDS. I authorize the release of any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit. I understand it is my responsibility to know all rules and restrictions of my insurance policy, to know which hospital, emergency rooms, laboratories, x-ray departments, specialists, and specialist providers which are assigned to me according to my insurance policy rule. It is Jack Von Bulow, DDS's procedure to share Protected Health Information with labs, x-rays, consulting physicians, and hospitals. We will call the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary Protected Health Information for each transaction.

Reset Signature

Date:

Medical History

Name of Personal Physician and/or their specialty

Most recent physical exam

What is your estimate of your general health?

Excellent

Good

Fair

Poor

Medical History - Women Only

Are you taking Birth Control or Hormones?

Yes No

Are you pregnant?

Yes No

If pregnant, what is your delivery date?Possibly pregnant or trying to get pregnant?